all heart sounds and murmurs

Question 1

cause of heart sounds in general

Answer 1

turbulent blood flowtensing of cardiac structuresvalve closure

Question 2

cause of S1 heart sound

Answer 2

AV (tricuspid and mitral) valve closure

Question 3

what phase of cardiac cycle is S1

Answer 3

start of systole - isovolumic contraction

Question 4

phases of the cardiac cycle

Answer 4

isovolumic contraction - period between which AV valves shut, SL valves open; ventricles contracting in a closed circuit
rapid ejection - opening of SL valves; c wave in JVP
reduced ejection - slowing of ejection ultimately causing closure of SL valves (aortic and pulmonary trunk pressures >ventricular pressure)isovolumic relaxation - relaxation of ventricles when both AV and SL valves are shut; V wave in JVPrapid ventricular filling - AV valves open causing rapid filling; y descent in jvpdiastasis - as filling of ventricles nears ~80%atrial systole - atria contract to top of the ventricles with last amount of blood; a wave in jvp

Question 5

cause of S2 heart sound

Answer 5

SL (pulmonary and aortic) valve closure

Question 6

what phase of cardiac cycle is S2

Answer 6

end of systole/beginning of diastole - isovolumic relaxation

Question 7

cause of S3 heart sound

Answer 7

volume overload
tensioning of chordae tendinae at the end of rapid ventricular filling
sudden deceleration of blood against LV

Question 8

cause of S4 heart sound

Answer 8

pressure overload

reflection of atrial wave against a poorly compliant ventricle (thickened or stiff)

Question 9

pathologies where S4 is seen

Answer 9

LV hypertrophy secondary to HTN
aortic stenosis,acute MR
IHD, age +++
angina, MI sometimes - only thing seen acutely

Question 10

pathologies where S3 is seen

Answer 10

normal in young people and athletes
in older people - congestive heart failure
physiological - thyrotoxicosis, pregnancy

Question 11

symptoms of MS

Answer 11

dyspnea, orthopnea, PND - increased left atrial pressure
hemoptysis - ruptured bronchial veins
ascites, edema, fatigue - pulmonary HTN, decrease CO

Question 12

signs of MS

Answer 12

mitral facies

peripheral cyanosis

Question 13

pulse of MS

Answer 13

normal or reduce in volume - reduced CO

AF may be caused if left atrial enlargement

Question 14

JVP in MS

Answer 14

normal height
prominent a wave if pulmonary HTN present
loss of a wave if AF

Question 15

palpation in MS

Answer 15

tapping apex beat
RV heave
palpable P2

Question 16

auscultation in MS

Answer 16

T/C - mid diastolic low pitched rumbling diastolic murmur
R - nil
loud S1 - valve cusps remain wide open at onset of systole
loud or palpable P2 if pulmonary HTN
opening snap - high LA pressure forces valve open

Question 17

accentuation manoeuvres in MS

Answer 17

exercise

left lateral position

Question 18

causes of MS

Answer 18

RHD

congenital parachute valve

Question 19

MR symptoms

Answer 19

dyspnea - increased LA pressure

fatigue - decreased CO

Question 20

MR signs

Answer 20

tachypnea

Question 21

MR pulse

Answer 21

normal or sharp upstroke due to rapid ventricular decompression
AF relatively common

Question 22

JVP in MR

Answer 22

n/a

Question 23

palpation in MR

Answer 23

displaced, diffuse and hyperdynamic apex beat
pansytolic thrill occasionally present at apex
parasternal heave due to LA enlargement behind the RV

Question 24

auscultation in MR

Answer 24

T/C - pansytolic murmur maximal at apex and usually radiating towards axilla
soft or absent S1-
LV S3 due to rapid LV filling in early diastole

Question 25

MR accentuation manoeuvres

Answer 25

valsalva - longer and louder

Question 26

causes of MR

Answer 26

mitral valve prolapse degeneration associated with age RHD papillary muscle dysfunction due to LV failure or ischemia cardiomyopathy - hypertrophic, dilated or restrictive CT diseases congenital

Question 27

AR symptoms

Answer 27

occurs in late stage of disease exertional dyspnea, fatigue, exertional angina - decreased CO palpitations - hyperdynamic circulation

Question 28

AR signs

Answer 28

none specifically but marfanoid features Ankolysing spondylitis or other seronegative arthropathies

Question 29

AR pulse and BP

Answer 29

collapsing pulse 'water hammer' - most obvious if raising patient's arm while feeling radial pulse wide pulse pressure - DBP very low as leaking back constantly, SBP normal bisfiriens pulse - severe AR - venturi effect - rapid ejection and brief in drawing of aortic wall leading to a diminution of the pulse followed by rebound increase

Question 30

AR JVP/neck

Answer 30

prominent carotid pulsations

Question 31

AR palpation

Answer 31

displaced and dyskinetic apex beat | diastolic thrill may be felt at LSE if sitting up and exhaling

Question 32

AR auscultation

Answer 32

T/C - early diastolic, decrescendo quality, high pitched. may extend for variable time into diastole loudest at 3/4 ICS soft A2 component systolic ejection murmur usually also present - aortic stenosis or turbulent flow across normal diameter aortic valve

Question 33

AR accentuation manouvres

Answer 33

expiration and leaning forward

Question 34

acute AR causes

Answer 34

valvular - IE | aortic root - marfan's syndrome - aortic dissection

Question 35

chronic AR causes

Answer 35

``` valvular RHD (rarely the only murmur if so) congenital (bicuspid valve, VSD) seronegative arthropathy esp ankolysing spondylitis aoritc root dilation marfan's aortitis rheumatoid arthritis teritary syphilis dissecting aneurysm ```

Question 36

differentiate acute AR to chronic AR

Answer 36

acute - no collapsing pulse (BP is low) and diastolic murmur is short

Question 37

AS symptoms

Answer 37

exertional chest pain (50% no CAD) | exertional dyspnea and exertional syncope

Question 38

AS signs

Answer 38

usually nothing remarkable

Question 39

AS pulse

Answer 39

``` plateau pulse (anacrotic) OR late peaking and low volume (tardus et parvus) ```

Question 40

AS JVP

Answer 40

n/a

Question 41

AS palpation

Answer 41

hyperdynamic apex beat may be slightly displaced systolic thrill at base of heart (in aortic area)

Question 42

AS auscultation

Answer 42

T/C - harsh (mid)systolic ejection murmur, crescendo - decrescendo R - maximal over aortic area and extending into carotids, may extend widely over precordium and extend to apex narrowly split or reversed S2 - delayed LV ejection

Question 43

AS accentuation manouvres

Answer 43

sitting up and in full expiration | note - associated aortic regurg is common

Question 44

AS causes

Answer 44

degenerative calcific aortic stenosis - elderly calcific in younger patients - congenital bicuspid valve rheumatic